Longcase:A 70 yearold male patient with SOB
LONGCASE -PRACTICAL FINAL EXAMINATION(70 yearold male with shortness of breath)
Hallticket no:1701006159
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CASE PRESENTATION:-
A 70 year old male came to OPD with the
Chief Complaints of:-
-Shortness of breath since 20 days.
-Cough since 20 days.
History of presenting illness:
TIMELINE OF EVENTS:
Patient was apparently asymptomatic
20 days back:
Patient complains of
SHORTNESS OF BREATH:
*It was insidious in onset, gradual in progression- Grade 2
*Not associated with wheezing, No postural variation, No diurnal variation.
*No history of orthopnea and PND, Relieved on Rest.
COUGH:
*Cough is present on and off with sputum- *Mucoid in consistency,Not blood stained,Not foul smelling,No diurnal and nocturnal variation, It was relieved on medication.
*Loss of weight and loss of appetite is present.
*No history of fever,palpitations, chest pain, chest tightness,decreased urine output,syncopal attacks.
1day back:
Patient presented to the OPD with above complaints.
PAST HISTORY:
*Patient had similar complaints in the past and went to a local hospital where he was treated with intercostal tube drainage.
Patient had history of TB 10 years back and used medications for TB for 4 months.
Not a known case of Diabetes Mellitus Hypertension,Asthma and epilepsy
Family History:-
Not significant
Personal History:-
Diet:Mixed diet
Apetite:Decreased
Sleep: Adequate
Bowel and Bladder habits:Normal
Allergies:No
Addictions:-
Alcoholic since 50 years and Chronic smoker-smoked for 40 years-1chutta per day, stopped 10 years back.
General Physical Examination:-
•Patient is conscious,coherent and cooperative and well oriented to time, place and person.
•He is moderately built.
•Pallor:- Absent
•Icterus:-Absent
•Cyanosis:- Absent
•Clubbing :- Absent
•Lymphadenopathy:- Absent
•Edema:-Absent
Vitals:-
•Patient is afebrile
•Pulse rate:-82 bpm
•Blood pressure:-130/80 mm of Hg
•Respiratory rate:-28 cpm
•SpO2:-96% on Room temperature
•GRBS:-113mg%
Clinical Images:-
Systemic Examination:-It is done with consent if patient in sitting position in a well lit room .
Respiratory System:-
Inspection:
UPPER RESPIRATORY TRACT:
NOSE:-No DNS, polyps,turbinate hypertrophy
ORAL CAVITY-Poor oral hygiene
POSTERIOR PHARYNGEAL WALL:-Normal
LOWER RESPIRATORY TRACT:
Shape of the chest:-bilaterally symmetrical,Elliptical
Trachea:- Appear to be central
Apical impulse is not appreciated.
Chest Expansion:Decreased chest expansion on right side.
Chest Movements:Decreased ln rightside
No usage of Accessory muscles of respiration
No dilated veins,scars, sinuses.
No kyphosis/Scoliosis
Palpation:
All Inspectory findings are confirmed.
No local rise of temperature.
Trachea:- midline in position
Apical impulse is felt at the left 5th intercoastal space.
Tactile Vocal fremitus:- decreased on right side infrascapular and infraaxillary area
Chest circumference:- inspiration:- 74cm
expiration:- 75cm
AP diameter:21cms
Transverse diameter:25cms
Right hemithorax:-39 cm
Left hemithorax:-39 cm
•Dullness noted in right sided Infrascapular area and infraaxillary area
•Done on both sides in the following areas:-
-Supraclavicular-resonant on both sides
-Infraclavicular-resonant on both sides
-Mammary-resonant on both sides
-Axillary-resonant on both sides
-Infraaxillary-Stony dull note on right side, Resonant on left side
-Suprascapular-resonant on both sides
-Infrascapular-Stony dull note on right side , Resonant on left side
-Upper/mid/lower interscapular-Resonant on both sides
Auscultation:-
Done on both sides of the chest.
*Bilateral Air Entry:- Present
*Decreased Air Entry on Right Infrascapular and Infraxillary area
*Vocal Resonance:- Decreased on Right Infraxillary area
*No added sounds.
Abdomen Examination:-
Inspection:-
Shape – scaphoid
Flanks – free
Umbilicus –central in position , inverted.
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
Palpation:-
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
Percussion:-
There is no fluid thrill and shifting dullness.
Auscultation:-
Bowel sounds are heard.
Cardiovascular system Examination:-
Inspection:-
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
Apical impulse and pulsations cannot be appreciated
Palpation:-
Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
No parasternal heave, thrills felt
Auscultation:-
S1 and S2 heard , no added thrills and murmurs heard.
Central nervous system:-
Higher Mental Functions:-
Patient is Conscious, well oriented to time, place and person.
All cranial nerves:-intact
Motor system:-Intact
Superficial reflexes and deep reflexes:-present and normal
Gait:- normal
No involuntary movements
Sensory system:-All sensation(pain, touch, temperature, position, vibration sense)are well appreciated.
Provisional Diagnosis:- Right sided Pleural Effusion secondary to Tuberculosis.
Investigations:-
Complete Blood Picture:
HIV rapid: 
ULTRASOUND:
*Right moderate pleural effusion
*Bliateral minimal consolidatory changes in chest
CHESTXRAY:
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